1
|
Pearson DJ, Sharma A, Lospinoso JA, Morris MJ, McCann ET. Effects of Electrolyte Replacement Protocol Implementation in a Medical Intensive Care Unit. J Intensive Care Med 2016; 33:574-581. [PMID: 27881698 DOI: 10.1177/0885066616679593] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE To evaluate the effects of electrolyte replacement protocol (ERP) implementation in the medical intensive care unit (MICU) setting. We hypothesized that a protocol would reduce the time of replacement dose administration and increase provider satisfaction with the process of electrolyte replacement. METHODS This was a retrospective review of electronic medical record data before and after implementation of a standardized ERP in an 18-bed military tertiary care MICU. RESULTS Median time from abnormal laboratory result to time of documented dose administration for potassium decreased from 180 to 98 minutes ( P < .01), phosphorus decreased from 190 to 135 minutes ( P < .01), calcium decreased from 95 to 61 minutes ( P < .01), and magnesium decreased from 155 to 149 minutes ( P < .01). Overall, there was a significant reduction in time to electrolyte repletion from 146 to 98 minutes ( P < .01) for all electrolytes. Nursing satisfaction for autonomy, timeliness, effectiveness, and the need to seek orders was all improved ( P < .01), and physicians saved 4.4 minutes/patient/day ( P = .04). CONCLUSIONS Electrolyte replacement protocols can be safely implemented in the MICU and reduce the time from abnormal laboratory result to electrolyte replacement dose administration. They can improve provider satisfaction and reduce physician time with the process of electrolyte replacement.
Collapse
Affiliation(s)
- Daniel J Pearson
- 1 San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| | - Anit Sharma
- 1 San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| | | | - Michael J Morris
- 1 San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| | - Edward T McCann
- 1 San Antonio Military Medical Center, JBSA Fort Sam Houston, TX, USA
| |
Collapse
|
2
|
Peng Y, Huang FY, Liu W, Zhang C, Zhao ZG, Huang BT, Liao YB, Li Q, Chai H, Luo XL, Ren X, Chen C, Meng QT, Huang DJ, Wang H, Chen M. Relation between admission serum potassium levels and long-term mortality in acute coronary syndrome. Intern Emerg Med 2015; 10:927-35. [PMID: 25986480 DOI: 10.1007/s11739-015-1253-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
Abstract
Serum potassium homeostasis play an important role in myocardial function, but the impact of serum potassium levels on long-term mortality has not been well evaluated. In the current study, we investigated patients with acute coronary syndrome (ACS) and analyzed the relationship between admission serum potassium levels and long-term mortality. Between July 2008 and September 2012, 2369 patients with ACS that was confirmed by coronary angiography were enrolled in this study and completed the follow-up. The serum potassium level was evaluated within first 24 h after admission. The primary outcome in this study was all-cause mortality. Patients were categorized into five groups to determine the relation between admission serum potassium levels and long-term mortality: < 3.5, 3.5 to < 4.0, 4.0 to < 4.5, 4.5 to < 5.0, and > 5 mEq/L. There was a U-shaped relationship between admission serum potassium levels and long-term mortality that persisted after multivariable adjustment. The mortality risk was lowest in the group of patients with potassium levels of 3.5 to < 4.0 mEq/L, whereas mortality was higher in patients with potassium levels > 4.5 [hazard ratio (HR) 1.62, 95 % confidence interval (CI) 0.90 to 2.93 and HR 1.55, 95 % CI 0.54 to 4.49, for patients with potassium levels of 4.5 to < 5.0 mEq/L and ≥ 5.0 mEq/L, respectively] or < 3.5 mEq/L (HR 2.14, 95 % CI 1.28 to 3.59). There was a U-shaped relationship between admission serum potassium levels and long-term mortality for ACS patients; in particular, among the examined patients, the lowest mortality was observed in those with admission serum potassium levels of between 3.5 and < 4.5 mEq/L compared with those who had higher or lower potassium levels.
Collapse
Affiliation(s)
- Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Fang-yang Huang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Wei Liu
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Chen Zhang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Zhen-gang Zhao
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Bao-tao Huang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Yan-biao Liao
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Qiao Li
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Hua Chai
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Xiao-lin Luo
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Xin Ren
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Chi Chen
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Qing-tao Meng
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - De-jia Huang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China
| | - Hua Wang
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China.
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, 37 Guoxue Street, Chengdu, 610041, People's Republic of China.
| |
Collapse
|
3
|
Calcium supplementation during sepsis exacerbates organ failure and mortality via calcium/calmodulin-dependent protein kinase kinase signaling. Crit Care Med 2013; 41:e352-60. [PMID: 23887235 DOI: 10.1097/ccm.0b013e31828cf436] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Calcium plays an essential role in nearly all cellular processes. As such, cellular and systemic calcium concentrations are tightly regulated. During sepsis, derangements in such tight regulation frequently occur, and treating hypocalcemia with parenteral calcium administration remains the current practice guideline. OBJECTIVE We investigated whether calcium administration worsens mortality and organ dysfunction using an experimental murine model of sepsis and explored the mechanistic role of the family of calcium/calmodulin-dependent protein kinases in mediating these physiological effects. To highlight the biological relevance of these observations, we conducted a translational study of the association between calcium administration, organ dysfunction, and mortality among a cohort of critically ill septic ICU patients. DESIGN Prospective, randomized controlled experimental murine study and observational clinical cohort analysis. SETTING University research laboratory and eight ICUs at a tertiary care center. PATIENTS A cohort of 870 septic ICU patients. SUBJECTS C57Bl/6 and CaMKK mice. INTERVENTIONS Mice underwent cecal ligation and puncture polymicrobial sepsis and were administered with calcium chloride (0.25 or 0.25 mg/kg) or normal saline. MEASUREMENTS AND MAIN RESULTS Administering calcium chloride to septic C57Bl/6 mice heightened systemic inflammation and vascular leak, exacerbated hepatic and renal dysfunction, and increased mortality. These events were significantly attenuated in CaMKK mice. In a risk-adjusted analysis of septic patients, calcium administration was associated with an increased risk of death, odds ratio 1.92 (95% CI, 1.00-3.68; p = 0.049), a significant increase in the risk of renal dysfunction, odds ratio 4.74 (95% CI, 2.48-9.08; p < 0.001), and a significant reduction in ventilator-free days, mean decrease 3.29 days (0.50-6.08 days; p = 0.02). CONCLUSIONS Derangements in calcium homeostasis occur during sepsis that is sensitive to calcium administration. This altered calcium signaling, transduced by the calmodulin-dependent protein kinase kinase cascade, mediates heightened inflammation and vascular leak that culminates in elevated organ dysfunction and mortality. In the clinical management of septic patients, calcium supplementation provides no benefit and may impose harm.
Collapse
|
4
|
Hoekstra M, Vogelzang M, van der Horst IC, Lansink AO, van der Maaten JM, Ismael F, Zijlstra F, Nijsten MW. Trial design: Computer guided normal-low versus normal-high potassium control in critically ill patients: Rationale of the GRIP-COMPASS study. BMC Anesthesiol 2010; 10:23. [PMID: 21194419 PMCID: PMC3022901 DOI: 10.1186/1471-2253-10-23] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 12/31/2010] [Indexed: 01/04/2023] Open
Abstract
Background Potassium depletion is common in hospitalized patients and can cause serious complications such as cardiac arrhythmias. In the intensive care unit (ICU) the majority of patients require potassium suppletion. However, there are no data regarding the optimal control target in critically ill patients. After open-heart surgery, patients have a strongly increased risk of atrial fibrillation or atrial flutter (AFF). In a novel trial design, we examined if in these patients different potassium control-targets within the normal range may have different effects on the incidence of AFF. Methods/Design The "computer-driven Glucose and potassium Regulation program in Intensive care Patients with COMparison of PotASSium targets within normokalemic range (GRIP-COMPASS) trial" is a single-center prospective trial in which a total of 1200 patients are assigned to either a potassium control-target of 4.0 mmol/L or 4.5 mmol/L in consecutive alternating blocks of 50 patients each. Potassium levels are regulated by the computer-assisted potassium suppletion algorithm called GRIP-II (Glucose and potassium regulation for Intensive care Patients). Primary endpoint is the in-hospital incidence of AFF after cardiac surgery. Secondary endpoints are: in-hospital AFF in medical patients or patients after non-cardiac surgery, actually achieved potassium levels and their variation, electrolyte and glucose levels, potassium and insulin requirements, cumulative fluid balance, (ICU) length of stay, ICU mortality, hospital mortality and 90-day mortality. Discussion The GRIP-COMPASS trial is the first controlled clinical trial to date that compares potassium targets. Other novel methodological elements of the study are that it is performed in ICU patients where both targets are within the normal range and that a computer-assisted potassium suppletion algorithm is used. Trial registration NCT 01085071 at ClinicalTrials.gov
Collapse
Affiliation(s)
- Miriam Hoekstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, the Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
5
|
Hoekstra M, Vogelzang M, Drost JT, Janse M, Loef BG, van der Horst ICC, Zijlstra F, Nijsten MWN. Implementation and evaluation of a nurse-centered computerized potassium regulation protocol in the intensive care unit--a before and after analysis. BMC Med Inform Decis Mak 2010; 10:5. [PMID: 20100342 PMCID: PMC2826292 DOI: 10.1186/1472-6947-10-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 01/25/2010] [Indexed: 12/23/2022] Open
Abstract
Background Potassium disorders can cause major complications and must be avoided in critically ill patients. Regulation of potassium in the intensive care unit (ICU) requires potassium administration with frequent blood potassium measurements and subsequent adjustments of the amount of potassium administrated. The use of a potassium replacement protocol can improve potassium regulation. For safety and efficiency, computerized protocols appear to be superior over paper protocols. The aim of this study was to evaluate if a computerized potassium regulation protocol in the ICU improved potassium regulation. Methods In our surgical ICU (12 beds) and cardiothoracic ICU (14 beds) at a tertiary academic center, we implemented a nurse-centered computerized potassium protocol integrated with the pre-existent glucose control program called GRIP (Glucose Regulation in Intensive Care patients). Before implementation of the computerized protocol, potassium replacement was physician-driven. Potassium was delivered continuously either by central venous catheter or by gastric, duodenal or jejunal tube. After every potassium measurement, nurses received a recommendation for the potassium administration rate and the time to the next measurement. In this before-after study we evaluated potassium regulation with GRIP. The attitude of the nursing staff towards potassium regulation with computer support was measured with questionnaires. Results The patient cohort consisted of 775 patients before and 1435 after the implementation of computerized potassium control. The number of patients with hypokalemia (<3.5 mmol/L) and hyperkalemia (>5.0 mmol/L) were recorded, as well as the time course of potassium levels after ICU admission. The incidence of hypokalemia and hyperkalemia was calculated. Median potassium-levels were similar in both study periods, but the level of potassium control improved: the incidence of hypokalemia decreased from 2.4% to 1.7% (P < 0.001) and hyperkalemia from 7.4% to 4.8% (P < 0.001). Nurses indicated that they considered computerized potassium control an improvement over previous practice. Conclusions Computerized potassium control, integrated with the nurse-centered GRIP program for glucose regulation, is effective and reduces the prevalence of hypo- and hyperkalemia in the ICU compared with physician-driven potassium regulation.
Collapse
Affiliation(s)
- Miriam Hoekstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
6
|
Dünser MW, Hasibeder WR. Sympathetic overstimulation during critical illness: adverse effects of adrenergic stress. J Intensive Care Med 2009; 24:293-316. [PMID: 19703817 DOI: 10.1177/0885066609340519] [Citation(s) in RCA: 330] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The term ''adrenergic'' originates from ''adrenaline'' and describes hormones or drugs whose effects are similar to those of epinephrine. Adrenergic stress is mediated by stimulation of adrenergic receptors and activation of post-receptor pathways. Critical illness is a potent stimulus of the sympathetic nervous system. It is undisputable that the adrenergic-driven ''fight-flight response'' is a physiologically meaningful reaction allowing humans to survive during evolution. However, in critical illness an overshooting stimulation of the sympathetic nervous system may well exceed in time and scope its beneficial effects. Comparable to the overwhelming immune response during sepsis, adrenergic stress in critical illness may get out of control and cause adverse effects. Several organ systems may be affected. The heart seems to be most susceptible to sympathetic overstimulation. Detrimental effects include impaired diastolic function, tachycardia and tachyarrhythmia, myocardial ischemia, stunning, apoptosis and necrosis. Adverse catecholamine effects have been observed in other organs such as the lungs (pulmonary edema, elevated pulmonary arterial pressures), the coagulation (hypercoagulability, thrombus formation), gastrointestinal (hypoperfusion, inhibition of peristalsis), endocrinologic (decreased prolactin, thyroid and growth hormone secretion) and immune systems (immunomodulation, stimulation of bacterial growth), and metabolism (increase in cell energy expenditure, hyperglycemia, catabolism, lipolysis, hyperlactatemia, electrolyte changes), bone marrow (anemia), and skeletal muscles (apoptosis). Potential therapeutic options to reduce excessive adrenergic stress comprise temperature and heart rate control, adequate use of sedative/analgesic drugs, and aiming for reasonable cardiovascular targets, adequate fluid therapy, use of levosimendan, hydrocortisone or supplementary arginine vasopressin.
Collapse
Affiliation(s)
- Martin W Dünser
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse, Innsbruck, Austria.
| | | |
Collapse
|
8
|
Palevsky PM. Perioperative management of patients with chronic kidney disease or ESRD. Best Pract Res Clin Anaesthesiol 2004; 18:129-44. [PMID: 14760878 DOI: 10.1016/j.bpa.2003.08.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The perioperative management of patients with chronic kidney disease (CKD) or dialysis-dependent end-stage renal disease (ESRD) is complicated by both the underlying renal dysfunction, with associated disturbances of fluid and electrolyte homeostasis and altered drug clearance, and the presence of associated co-morbid conditions, including diabetes mellitus, chronic hypertension and cardiovascular and cerebrovascular disease. The impact of CKD on fluid and electrolyte management, haematological and cardiovascular complications and drug management in the perioperative period are reviewed. Special issues related to the management of haemodialysis and peritoneal dialysis patients in the perioperative period are also reviewed.
Collapse
|